Before You Enroll

Prepare for 2018 with a health insurance plan that fits your needs. Below, you’ll find a list of common questions that you may need answered before you enroll.

Be Confident

We want you to be confident in your choice of a health plan. The checklist below will help you make an informed decision. Let’s get started. Here are some questions you might have—with links to answers:

When can I enroll?

Open Enrollment for 2018 runs from November 1 – December 15. This is the period of time when anyone can enroll in an individual health insurance plan for the 2018 plan-year.

A Special Enrollment Period allows people to enroll in a plan outside of the Open Enrollment Period. To be eligible for an SEP, you must have undergone a qualifying life event like: Getting married, having a child or losing employer coverage. If you’re eligible, you have 60 days from the qualifying life event to enroll in a plan.

Are my doctors in network?

Find a Doctor to see if your physician is in the network. If you don’t have a doctor, My Care Navigator can help you find one. Call 888-258-3428.

Is my hospital in-network?

Highmark networks of hospitals and health care providers give you plenty of options to choose from that are close to home.

Are my prescriptions covered?

To check your prescriptions, visit the RX Formulary or drug benefit tool. It lists all prescription drugs that are covered by Highmark plans.

Am I covered when I travel?

For PA members, BlueCard® coverage is available only for emergency and urgent care when you are away from home. Routine care is not covered.

Am I still covered if I use UPMC providers?

Coverage for most UPMC providers and facilities is not included with my Direct Blue plans in western Pennsylvania. If a member covered under your plan is currently receiving care from a UPMC provider or at a UPMC facility under the protections of the Consent Decree, contact My Care Navigator at 1-888-258-3428 and we’ll help you find a new in-network provider. My Care Navigator will even help transfer your medical records to ensure that your new provider has all the information needed to continue your care and keep you healthy. Children’s Hospital of Pittsburgh of UPMC remains in-network for all plans.

Can I get financial assistance?

You may be eligible for financial help. A health insurance subsidy or tax credit could reduce your insurance costs. A subsidy or tax credit might also enable you to enroll in a more robust plan that better suits your needs. You can learn more and apply at

How do I enroll?

Starting November 1, we can help you enroll online. You must be enrolled by December 15 for coverage beginning January 1, 2018.

Can I talk to a real person?

Have questions? Give us a call at
Central PA: (855) 865-4326
Western PA: (855) 865-4325
Northeastern PA: (855) 856-0316
Delaware: (855) 329-1759
West Virginia: (855) 329-1758

Returning Members: Learn About Changes for 2018

We want to help you make the right decision for you and your family. See how the plans, doctors and hospitals available in your area will change for 2018.

See 2018 Plan Changes

Tips for Choosing the Right Plan

  • It’s a good idea to choose a plan that covers services you think you’ll use frequently, even if it means paying a higher monthly premium, because it will likely save you money in the long run.

  • Understand how cost sharing (like deductibles and copays) works on your plan. Although deductibles can sometimes seem overwhelming, many benefits are available before you meet your deductible.

  • Consider pairing qualified high-deductible plans with an HSA (Health Savings Account). HSAs allow you to use pre-tax income for health care expenses and can be used to pay your deductible. Account contributions are not taxed and funds in the account roll over. Consult your tax or financial advisor to learn more.

    If you have a primary care provider or specialist that you want to continue to see, make sure they are in the plan’s network or that you can afford to pay more to see them if they are “out-of-network. You may pay more or all of the charge if you see a health care provider who is out-of-network.

    All Highmark ACA plans include prescription drug coverage. The term “formulary” refers to a list of drugs your insurance plan covers. A drug’s formulary status may impact how much you pay for each drug. If you regularly take prescription medication, make sure that it is covered by the plan or that you can afford to pay more for it if it’s not covered.

  • Carefully consider copay and coinsurance rates for doctor visits, surgeries and prescriptions. Frequent copays and coinsurance payments can add up for brand name or specialty prescriptions and hospital care, even if you are staying in the network.

  • Thoroughly read and understand the coverage provided by the plans you are considering. Making the right decision now could save you time and money later.

    By considering the information listed above, you’ll be able to choose a plan that gives you the coverage you need at a price you can afford.

    Buying health insurance online in Delaware (DE), Pennsylvania (PA), and West Virginia (WV) is quick and easy, and we have resources to help you weigh cost, coverage, and network considerations.

Important Insurance Terms

1. Premium

The dollar amount you pay for your health insurance plan. Premium amounts are usually paid monthly, quarterly or yearly.

2. Office Visit Copayment (copay)

A fixed, upfront dollar amount (for example, $25) that you pay each time you receive certain health care services. The amount can vary based on the type of health care service you receive, such as filling a prescription drug, seeing your doctor or visiting a specialist. After paying your copay, your insurance company will usually pay the remainder of your bill for covered in-network care.

3. Deductible

The dollar amount you must pay each benefit period (usually a year) for your health care expenses before your plan begins to pay for covered in-network services. For example, if you have a $500 deductible, that’s the amount you will pay before your insurance plan will pay for covered in-network services. You will still be required to pay the plan copayments even after the deductible is met.

4. Coinsurance

Your part of a medical bill that you pay after reaching your deductible. For example, if your medical bill for covered, in-network services is $100 and your coinsurance is 20%, you pay $20. The insurance company pays $80.

5. Maximum Out-of-Pocket (Out-of-Pocket Limit)

The highest amount you will need to pay each benefit period (usually a year) for covered in-network care before your insurance company pays 100%. For example, if your out-of-pocket maximum is $2000, once you have paid $2000 the insurance company pays for 100% of the plan allowance for covered in-network care. This does not include any services not covered by your plan.

6. PCP

A Primary Care Provider (PCP) is the medical professional who provides a patient’s care and helps them access a range of health services. This could be a doctor, nurse practitioner, clinical nurse specialist or physician assistant, as allowed under state law.

7. Network

Doctors, hospitals, clinics, labs, and other providers that a health insurer has contracted with to provide health care services to its members. You usually pay less when you use health care providers that are “in-network.” You may pay extra or all charges if you see a health care provider who is “out-of-network.”

8. Formulary

A list of drugs your insurance plan covers. A drug’s formulary status may impact how much you pay for each drug.

9. Health Savings Account (HSA)

A tax-exempt savings account you can set up with a financial advisor to save for potential future medical expenses.

10. Cost-sharing

The share of costs covered by your insurance that you pay out of your own pocket. This term generally includes deductibles, coinsurance and copayments, or similar charges, but it doesn’t include premiums, balance billing amounts for non-network providers, or the cost of non-covered services.

11. Diagnostic Services

Lab work or tests ordered by a doctor or health care professional to learn more about a specific condition or disease. Examples include X-rays and blood tests.

12. Preventive Care

Screenings or routine services that may prevent or detect problems before they advance. For example, child wellness visits are preventive care.

13. Benefit Period

The specific period of time during which charges for covered services must be incurred in order to be eligible for payment by the health plan. A charge is considered incurred on the date a member receives a service or supply for which the charge is made.